Nystagmus Pembimbing: dr. Donny H Hamid SpSDisusun oleh: Nadira Danata 110201188

Definition An involuntary repetitive rhythmic oscillations of one or both eyes in one or all of the visual field . Can be either congenital or acquired , which is about the whole age.

Epidemiology 24 per 10,000 population 18 years: 16.6 per 10,000 population albinismAdult: 26.5 per 10,000 neurological diseaseCaucasian > AsianNo evidance gap between male and female

Eye Muscle

Vestibular System

Vestibular System

Connection underlying VOR

Others Central Vestibular Pathway

Physiology Three mechanisms are involved in maintaining foveal centration of an object of interest: - fixation of primary position: a) detect retinal image drift of foveating imageb) suppress unwanted saccadic movement- the vestibulo-ocular reflex- the neural integrator :a)required contraction of the extraocular muscleb)gaze holding network signalc)cerebellum, ascending vestibular pathway, oculomotor nuclei

Physiologically Induced NystagmusOptokinetic nystagmus: involuntary, conjugate, jerk nystagmus that is seen when a person gazes into a large moving field. The oscillations, which are in the plane of the moving fields.Consist of smooth pursuit and saccadic.

Physiologically Induced NystagmusVestibular nystagmus: occurs during self-rotation. It occurs due to the signals sent by the vestibular labyrinth to the vestibular nuclei and the cerebellum. Induced by irrigating ears.End-point nystagmus: a small amplitude conjugate jerk nystagmus on far eccentric gaze.

Congenital/ Infantile NystagmusCN- usually recognized in first few months of life- May have good vision or poor vision - Slow phase velocity increase exponentally- Conjugate, horizontal, and jerky- My occur without any ocular or central nervus system anomalies, may be associated with albinism, optic nerves hypoplasia, and congenital cataracts.- Near normal vision if they have develop foveation period- Amplified by attempted fixation- Dampened by convergence and darkness and certain gaze angle

MLN - Usually appears within first few months of life- the slow phase velocity decreases or remains the same- associated with strabismus, albinism, optic nerve hypoplasia, congenital cataract- frequently in patient with congenital uniocular loss/ visual deprivation

Acquired NystagmusVestibular nystagmusDown beating nystagmus (DBN)Torsional nystagmusPeriodic alternation nystagmusSee-saw nystagmusGaze evoked nystagmusINO

Vestibular nystagmusAs result from disease affecting the vestibular organ in the inner earUsually associated with vertigo

PERIPHERAL VS. CENTRAL VESTIBULAR NYSTAGMUS

Peripheral Central Unidirectional, fast phase opposite the lesion; Usually horizontal with torsionUnidirectional/ bidirectional; purely vertical or torsional nystagmusDampened by visual fixationNot dampened by visual fixationTinitus, deafness (+)Tinitus, deafness (-)Severe vertigoNon or mild vertigoCommonly peripheral vestibular organ dysfunction: labyrynthitis, menieres Etiologies commonly vascular, demyelination, pharmacologic, toxicDays to weeks durationOften chronic

DBNArnold Chiari Malformation, Lesions of the vestibulo-cerebellum (flocculus, paraflocculus, nodulus, and uvula), MLF, Ventral tegmentum, the anterior vernis of cerebellum

UBN1st type: large amplitude increases in intensity with upward gaze anterior vermis of cerebellum2nd type: small amplitude decreases in intensity with upward gaze, increases intensity in downward gaze medulla

Torsional nystagmusLession of the anterior and posterior SCC on the same side (lateral medullary synd)Fast phase directed away from the side of lessionAccentuated by stimulating otolith

Periodic Alternating NystagmusDistruption of the vestibulo-ocular at the pontomedulallary junction. Often linked to cerebellar diseaseConjugate, horizontal jerkFast phase beating 1-2 minutes, neutral phase 10-20 secs and repeat

See-saw NystagmusSellar and parasellar lessions (note that is rare form of pendular nystagmus in which the torsional components are disjunctive one eyerises and intors while the other falls and exorts);

Abducting Nystagmus in Internuclear Ophtalmoplegia (INO)Lession affecting the MLF, contralateral to MLF lessionUnilateral ischemiaBilateral multiple sclerosisAn adduction weakness on conjugate movements and a jerk nystagmus of the abducting eye are the classic ocular motor sign (dissociated nystagmus).

Eyes no longer move as one and nystagmus is present in one eye but not the other.In unilateral MLF lesions the eye fails to adduct towards the affected side.multiple sclerosis, brainstem infarction, haemorrhage, trauma, and drug toxicity (phenytoin).

Acquired Pendular Nystagmuscan occur in any plane, it can be monocular or have a greater intensity in one eye and typically remains pendular in all directions of gaze. wide range of brainstem and cerebellar disease including several disorders of myelin, and with drug toxicities. In multiple sclerosis

Gaze-evoked Nystagmusside-effect of drugs, including sedative, anti-convulsant and alcohol, as well as cerebellar disease.elicited when the patient attempts to maintain an eccentric eye position.

Gaze-evoked NystagmusThe oscillations are jerky, with a centripetal decreasing velocity exponential slow phase take the eyes away from the desire eye position, followed by a corrective fast phase. A failure of the step (or tonic) eye position command from the gaze-holding network (the neural integrator). After the eyes are returned to the primary position, a short-lived reflex nystagmus with quick phases opposite to the direction of the previous eccentric gaze oscillation can typically be seen in vestibulo-cerebellar diseases.

Examination of Nystagmuschecking the movement of the eyeballthe patient was told to continue to glance in one direction during 5 or 6 secondsNystagmoid movements of the eyes are present in many people at extremes gaze.Nystagmus present with the eyes deviated less than 30 from the midline is abnormal.

Examination of NystagmusWhere the nystagmus there should be checked:Type of movement: pendular/ jerk nystagmusPlanes: horizontal, vertical, or a mixture rotatoar.Frequency: (fast or slow)The amplitude (large or small, rough or smooth)Directions; the direction of the fast component. Degree:Grade I: nystagmus appears when glancing towards the fast component;Grade II: also there if looking ahead;Grade III: nystagmus also occur when glance towards the slow component.Duration: permanent or pass

Horizontal/ horizontal-rotatoar Vetibular nytagmus (peripheral)Vertical nystagmus brain stem (mesensephalon and m.o)Horizontal pons tegmentum and mesensephalonHorizontal-rotatoar/ rotatoar m.o

Retinal/ ocular nystagmusPhysiological: optokinetic nystagmusPathological: devective vision, fixation is impairedRapid PendularIncreasing when looking to sidesPersistent through lifetime

Vestibular nystagmusPhysiological

Pathological - slow phase to the lesion, fast phase to normal side, setle simultaneously- tinitus, hearing loss, vertigo- menieres disease, vestibular neuronitis, vascular damage

Positional nystagmusDix-hallpike maneuver

Diagnosis BPPV of the posterior canalDelay nystagmus with rotatory componentRepeated fatigues

Positional nystagmusPagnini-McClure maneuverLateral canal type

Central Nervus SystemDamage to the central vestibular connection in the VN and brain stemHorizontal, vertical, rotatory, dissociatedFast phase ditermined by direction of gazeVertigo seldomSips of other nuclear in brainstemVascular dis, neoplasm, demyelination, alcohol intoxication, drug tixocityCerebellar dis fast phase to the cerebellar damagePosterior fossa positional nystagmus

Differences between Peripheral and Central Nystagmus

Peripheral NystagmusCentral NystagmusVertigoHeavy LightLatency Yes No Habituation Yes No Direction Nystagmus contralateral lesionsNystagmus towards lesionDuration FatiguePersistentPlanesHorizontal/ horizontal rotatoarHorizontal, vertical, rotatoar, multi-directionalHead positionIncrease with the change of head positionnot truly evoked by the positional maneuver

Neuro Imaging (MRI)Electronystamograph

Treatment and medicationStop medications that induced nystagmus Removing the etilogyContact lenses